Are you A Candidate For Dental Implants?

dental implant evaluation

What Best Describes Your Condition? *

I Have All My Teeth

I'm Missing One Tooth

I'm Missing Multiple Teeth

I'm Missing All My Teeth

How Long Have You Been Missing Your Teeth? *

I'm Not Missing Teeth

Less Than A Year

More Than A Year

Are you currently wearing dentures? *

Yes

No

What made you reach out to our office? *

Tooth Pain

Missing Teeth

Insecurities about the way you look

All of the above

Select all that apply - Do you feel that tooth loss has affected your: *

Personal Life

Professional Life

Enjoyment of Food

Physical Comfort

Oral Health

Appearance/Self Confidence

Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods? *

Yes

No

What Is The Most Important Outcome You Are Seeking? *

Function - Eating, Chewing, Talking

Aesthetics - Beautiful, Natural Looking Teeth

Both Are Equally As Important

What Is The Most Important Factor That Has Prevented You From Getting Treatment? *

Time

Money

Fear

Can't Find The Right Dentist

Please Describe your current Oral Health situation and the challenges that you are Experiencing. *

What is your timeline to receive treatment? *

Very little, I'm in no rush

Moderate, Within 1-3 months

High, I need help now

Have you seen another dentist about your condition? *

No, This is my first consultation

Yes, I did not feel comfortable with the other practice

Yes, I'm looking to compare pricing

If this is a second opinion what type of implant solution are you looking for? *

Fixed Full Arch

Implant Supported Denture

Single Implant

Traditional Denture

Not Sure

Are You The Decision Maker In Regards To Your Dental & Healthcare? *

Yes

No

Most Dental Implant procedures are not covered by insurance. However we offer many payment plans that make it quite affordable and offer low monthly rates. Are you interested in a payment plan? *

Yes I am!

No I will not need a payment plan

Are You Interested in Learning About Our Easy Monthly Payment Plans? If So, What Dollar Range Would You Like To Pay Monthly *

No Financing

$150/Month

$250/Month

Over $350/Month

How Familiar are you with the "All-On-4" treatment? Scale of 1-10 *

For your convenience, we will send you the customized information in regards to pricing for dental implants via text and email *

Yes send me the information

No, I do not wish to receive information regarding pricing for dental implants

By selecting no, we want to make sure that you are aware that we will not be able to provide you with the pricing and information you have requested regarding Dental Implants, immediately. We will reach out via a phone call but if you would like an email and text regarding pricing, please opt-in below. *

Yes I consent to receive this information

I would like to schedule an appointment to talk in person

I would like to speak to someone via phone call to discuss

I do not want this information

First Name *

Last Name *

Phone *

Email *

Postal Code *

Our practice is located in Billings, MT. Are you willing to travel to our location? *

Yes

No

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I understand the information disclosed in this form may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations and the HITECH Act.

COMPLETE THIS EVALUATION TO INSTANTLY DISCOVER:

If You're A Candidate For Dental Implants
What treatment options are available for you
Pricing and financing options

BONUS!!

Receive A Special Promotion That Can Save You Hundreds!

Dr. William Winterholler

Dr. William Winterholler graduated from Skyview High School in 1996 and pursued his undergraduate at Brigham Young University in Provo, Utah. He attended dental school at Creighton University in Omaha Nebraska and graduated in 2005 in the top 10% of his class. Upon graduation from dental school, he entered private practice in Omaha and accepted a faculty position at Creighton University teaching operative dentistry. Dr. Winterholler has always had a love for Billings and the state of Montana and chose to bring his family back to the area in 2006. Since returning to Billings, Dr. Winterholler has pursued extensive continuing education in Dental Implants – Billings, Laurel technology, full mouth implant rehabilitation, Cosmetic Dentistry Billings – Cosmetic Dentist Laurel Winterholler Dentistry and numerous other techniques and procedures. He has a passion for excellent dentistry and enjoys utilizing the latest in dental technology, including CEREC. He prides himself in listening to his patients needs and trying to provide the best dentistry has to offer. He is active within the dental community, his church community and most importantly with his family.

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